Patient susceptibility to over‐trust: The case of off‐label prescribing

• Published date: 01 June 2022
• Author: M. Paula Fitzgerald,Farnoush Reshadi,Matthew Sarkees
• Date: 01 June 2022
• DOI: http://doi.org/10.1111/joca.12451

RESEARCH ARTICLE

Patient susceptibility to over-trust: The case

of off-label prescribing

M. Paula Fitzgerald

1

| Farnoush Reshadi

2

| Matthew Sarkees

3

1

Department of Marketing, John

Chambers College of Business and

Economics, West Virginia University,

Morgantown, West Virginia, USA

2

The Business School, Worcester

Polytechnic Institute, Worcester,

Massachusetts, USA

3

Marketing Department, School of

Business, Villanova University, Villanova,

Pennsylvania, USA

Correspondence

M. Paula Fitzgerald, Department of

Marketing, John Chambers College of

Business and Economics, West Virginia

University, PO Box 6025, Morgantown,

WV, USA.

Email: paula.fitzgerald@mail.wvu.edu

Abstract

Consumer researchers focus on two primary constructs

when studying pharmaceuticals: benefit and risk percep-

tions. Herein, we propose three variables that can influ-

ence how consumers view the benefit-to-risk profile of a

drug: (1) trust in the doctor, (2) susceptibility to over-

trust and (3) perceived maverickism. We find that the

more the consumer trusts a doctor, the greater the per-

ceived benefits of an off-label drug prescribed by that

doctor. This relationship is magnified when consumers

are susceptible to over-trusting their doctor. Off-label

prescribing also increases the perception that a doctor is

a maverick. We test the boundaries of these effects by

considering agency breach perceptions arising from

pharmaceutical firms' payments to prescribing doctors.

Agency breach perceptions reduce post-encounter doc-

tor trust. Overall, this work suggests that trust reduces

the likelihood that consumers will engage in the behav-

iors needed for the marketplace to correct itself.

KEYWORDS

agency theory, off-label prescribing, open payments database,

over-trust, prescription drugs, trust

1|PATIENT SUSCEPTIBILITY TO OVER-TRUST AND THE

MAVERICK EFFECT

Imagine the following scenario in the doctor-patient relationship:

Received: 25 February 2020 Revised: 26 January 2022 Accepted: 6 April 2022

DOI: 10.1111/joca.12451

© 2022 American Council on Consumer Interests.

J Consum Aff. 2022;56:849–875. wileyonlinelibrary.com/journal/joca 849

Jaime suffers from migraines. The pain is so bad that Jaime seeks the help of the trusted

family doctor, Dr. Meeds. After discussing Jaime's medical situation, Dr. Meeds prescribes

Gabapentin. Jaime fills the prescription, takes the medicine as prescribed on the label,

and reports at the follow-up visit that the headaches are getting better. Interestingly,

Dr. Meeds never tells Jaime that Gabapentinisbeingusedoff-label—the U.S. Food and

Drug Administration has not approved that drug for preventing migraines. Moreover,

according to the American Academy of Neurology, there is not enough scientific evidence

to support using Gabapentin to prevent migraines (Healthline, 2016).

This scenario illustrates asymmetric information between the patient (consumer) and the

doctor

1

(service provider). The doctor holds expert knowledge stemming from years of training

and practice working with patients. Yet, in this case, Dr. Meeds executes a completely legal

solution to migraines that is not approved by recognized authorities, including the U.S. Food

and Drug Administration (FDA) and the American Academy of Neurology. In addition,

Dr. Meeds fails to inform Jaime that the treatment lacks such approval. This scenario might

leave the rational bystander/observer thinking that a treatment unapproved by governmental

and nongovernmental authorities should give a consumer pause. The doctor's failure to disclose

relevant information may also be viewed as a breach of trust. Indeed, academics predict that a

breach of trust results in dissatisfaction with the provider and perhaps even a dissolution of the

relationship (Harmeling et al., 2015). However, our research suggests that it is highly probable

that Jaime will continue trusting Dr. Meeds and will rely upon the doctor's advice in the future.

We offer a story of patients' (consumers') trust in doctors (service providers). We show that

provider actions that would, under normal circumstances, breach consumer trust (e.g., failing

to disclose the lack of approval and lack of scientific evidence), matter less to trusting con-

sumers given off-label prescriptions. Initial trust begets future trust regardless of the doctor's

intervening prescribing behavior. We introduce “susceptibility to over-trust”as an individual-

level, formative construct that amplifies the effects of trust. We also introduce the concept of a

doctor as a “maverick,”a successful risk-taker. Finally, we explore whether perceptions of the

principal/agent relationship between prescriber and consumer moderate the biasing effects of

consumer trust. See Figure 1for an overview.

We contribute theoretically by considering the consumer's relationship with a member of the chan-

nel of distribution for prescription drugs. To date, much important work in prescription drug percep-

tions focuses on the effects of direct-to-consumer advertising (e.g., Aikin et al., 2019;Ball,2018). Yet, a

consumer must work with a doctor to legally obtain a prescription drug. Thus, constructs related to the

prescribing doctor (trust, maverickism and agency) represent important omitted variables.

The articleis organized as follows. First,we provide background regardingdifferent types of pre-

scribing behaviors. Next, we overview three core constructs in our model: trust, susceptibility to

over-trust,and perceived maverickism. Weexamine these constructs empirically, then proposeand

test the proposition that breachof agency moderates these findings. Finally, we integrate these find-

ings and discusstheir implications forconsumer well-being and thehealthcare industry.

2|DOCTOR PRESCRIBING BEHAVIOR AND ITS

RELEVANCE TO CONSUMERS

Once the FDA authorizes a drug for the market, doctors have wide latitude in prescribing

behavior. One way to classify prescribing behavior is to consider whether the drug is:

850 FITZGERALD ET AL.